The coronavirus pandemic has completely altered our daily lives including the lives of those grieving the loss of a loved one. With social distancing and lockdown in place, the latter are "twice bereaved" says Ali Madeeh Hashmi, Associate Professor of Psychiatry at the Lahore-based King Edward Medical University (KEMU).

"We are telling them they cannot gather together, cannot console each other, except perhaps over Zoom or Skype, cannot hug or sit together and do all of those things that lessen their pain. They have lost a loved one but are forbidden from gathering and consoling each other," he says.

For Sarah*, the lockdown has come as a godsend as she comes to grips with the sudden passing away of her 65-year-old mother, earlier this month. "I and my brother don't have to face scores of people coming to comfort us," says Sarah, adding that she cannot deal with the 'how did she die' question. "Responding to the same question over and over again would have taken a toll on me emotionally," she says.

"It's not that they don't mean well, but I am still coming to terms with the reality of her not being there," says the 39-year old HR professional. For her and her brother who is three years younger than her, it's like reliving the pain as 10 years ago their father had passed away in exactly the same, sudden manner — dying in his sleep. Neither parents had any underlying health conditions. Both times it was her brother who was the first to find the parent to be no more.

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Clinical psychologist, Dr Asha Bedar, points out that the healing process for grieving individuals and families may have been disrupted by the circumstances and the absence of an "external support system" that involves "meeting people, talking about the deceased, turning to friends and family to cry with, receiving practical support such as help with arrangements, meals, and legal requirements".

"The exercise of mourning for the death of a loved one gives comfort and helps in processing the grief," agrees Dr Ayesha Mian, Associate Professor at the Aga Khan University Hospital. "Cultural rituals, norms, the human touch, the last words, the idea that you were there to comfort them and bid them goodbye are all ways to soldier through the grief that is to come," she adds.

"Guilt, non-closure, helplessness due to the inability to tell the deceased how much they were loved is a complicated bereavement and can occasionally lead to a depressive episode," says Dr Mian, adding: "People are feeling that now. I have had calls and communications from patients and others about their anxieties around their elderly loved ones; the stories of people dying alone that are coming from our physician friends and colleagues in the US and UK, away from loved ones, and the sheer helplessness to do anything about it is heartbreaking."

Return to normalcy

Along with a weakened external support mechanism, says Dr Bedar, the natural internal coping mechanisms of those undergoing the process of grieving had also become limited.

After the initial days of mourning, slowly returning to the daily humdrum is also an important part of the healing process, she says. "Going to work or class, socialising, day to day routine activities (school pick and drop, groceries, other errands), eventually returning to or picking up new hobbies or other pastimes or classes are all tremendously helpful through the process," she says, explaining that with social distancing an urgent need and with all public activity having come to a halt, many of those who have lost their loved ones may have limited mechanisms for this kind of distraction.

She gave the example of a client who told her how her work and keeping a daily routine — going for grocery shopping, visiting her elderly parents, and occasionally meeting up with friends kept her going after she lost a close family member just before the lockdown. "These breaks in thinking sad thoughts and missing the deceased all the time helped her move forward. But now not only has all outside activity stopped, including visits to her mother, adding both to her grief and anxiety," says Bedar.

However, that is not the case with Sarah. "I think I prefer working from home right now. It would have been difficult to face people and answer their questions. This way I can work at my pace and I don't need to put up a front," she says. Sarah also prefers not having the routine she had before the lockdown. "It would have been a constant reminder of mom not being around. This is giving me time to heal around loved ones," she emphasises.

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"I am more relieved because of the lockdown that I do not have a string of visitors coming over," says 65-year-old Sakina*, whose husband passed away two weeks back. "I am a private person, and cherish this alone time," she says, adding: "I am at peace because my husband is out of his misery and in a better place. He was very sick and the doctors had already prepared me."

With neither her husband's or her own next of kin in Karachi, she was on her own to carry out the most difficult tasks of booking and arranging for the ambulance to have her husband's body shifted from their home to the mortuary, buying the kafan (the white sheet to enshroud the body of the dead), as well as getting her husband's grave prepared. "When I look back, I am astonished at how and where I found the courage to do all that," says Sakina.

Routine is good

For many in grief, says Dr Bedar, nothing is better than to maintain a routine to heal from pain. "If routine and structure are important to and helpful in managing grief, there is nothing to stop them from creating a new (temporary) one during this time; whether it's getting dressed every morning, talking to loved ones online in case they don't live with you, taking an online gym or art class, studying, or in some cases even working. There are many ways of recreating some version of these at home, using technology and social media."

Sakina is settling down in a new routine that is helping her cope in her own way. "I am reading up more, cleaning up my house, also going into the kitchen, and spending more time with my parents," she says.

For many, says Dr Bedar, it could be a good time to take up something new. "A new skill or hobby for pure distraction; a new TV show, a small home-based project, anything that absorbs them for even a little bit and allows them to take a break from the sadness and sense of loss and to engage in something positive," she recommends.

Turning to faith

Four years ago, after her husband was diagnosed with Parkinson's disease, Sakina turned to religion. "I was always God-fearing but then I became more regular in my practice. It gave me immense solace and courage to get through my travails," she says.

"That is a strength in cultures like ours," agrees Dr Hashmi, while pointing out that in some ways, it can become a medical liability if patients, their families, and even our doctors become too passive and fatalistic. He adds with concern that "if prayer becomes a substitute for action rather than complement it, it's going to become very difficult in the coming weeks and months".

He says he would also tell bereaved families to be mindful of the medical precautions that need to be taken to protect themselves and other family members and loved ones. "If they want to pray and recite the Holy Quran etc, that's wonderful but please avoid all gatherings; maintain appropriate social distance, and continue to take the necessary infection prevention precautions until Covid-19 subsides."

"Because I have two elderly parents to take care of, I had messaged my friends and relatives to not visit me," says Sakina. In fact, she says, even for her husband's ghusal (last bath), namaz-i-janaza (funeral prayer) and burial, there were just six people — four people who work in her house and her husband's two nephews.

In addition, says Dr Hashmi, he would advise people who are grieving to eat healthy food, exercise, get enough sleep, and keep busy. "Eventually, it will become easier to remember the departed loved one without feeling the overwhelming pain that they are feeling now," he says, advising to focus on loving those who are still around.

Sort your life by sorting out the deceased's things

Dr Bedar points out that for some people the "forced" slow pace of life may mean time to attend to their grief and emotions. "This may even actually help, at least in the short term. Without the pressure to rush to work or run errands outside the house, the grieving may get more time to give their bodies and minds a rest as they process their grief," she says.

Giving the example of a client who said he finally got time to sit down "think, cry and focus", she said he has involved himself in "organising family pictures, letters and sorting through the things of the deceased, allowing himself time to let his feelings in".

Sakina cannot bring herself to do that. "I've cleaned my husband's cupboards, but I have not been able to clear out this stuff from the room. And I cannot bear to look at his photos or go through his papers and documents," she says.

Sarah says it is "too fresh" for her to pack or put her mother's things away right now. "I don’t think my brother or I have the heart to do it right away," she says.

Grieving is harder in these already traumatic times

Grieving is painful enough in normal times, but it is much harder because of the additional stress of these times, says Dr Bedar. "Many people at this time are experiencing heightened anxiety because of drastic changes in routines, financial worries, health worries, additional responsibilities, uncertainty about the future and/or the absence of normal stress management activities, making grief even more painful to manage," she adds.

And then there are people who have lost their loved ones to Covid-19 itself. "They have another set of emotional issues to contend with in their grief," says Dr Bedar, explaining: "For example, guilt and regret (with thoughts such as perhaps more caution could have been taken) or anger directed towards external factors (such as people, government etc.) for creating circumstances that may have led to loved ones be caught by the infection. It is natural for us as we grieve to look for reasons, people, and situations to blame, including often ourselves," she points out.

According to Dr Hashmi, mental health professionals like him expect to see a spike in cases of anxiety, depression, and post-traumatic stress disorder in the coming weeks and months. "But it is not just in the family members and loved ones of those who have died but also in healthcare workers and their families who have been traumatised in other ways due to this deadly illness," he says.

Carrying on with life

The "rituals of grief" explained Dr Hashmi differ from culture to culture. "Some cultures (Egypt, for instance) encourage open expression of grief; crying, wailing, shrieking, chest beating. Others, like Indonesia, encourage composure and silence. Our culture encourages religious expression: recitation of the Holy Quran, duas etc." But, he added, all these injunctions serve a definite purpose: "A way of severing of the physical and emotional ties that bind the dead person to the living."

Agreeing, Dr Bedar says dealing with loss was always about "carrying on with life while adjusting to a new way of being". In a lockdown, the newness and adjustment are doubled, says Dr Bedar.

As with grieving at any other time, the most effective strategies, she says are the ones that feel the most "natural, are at their own pace and that are some combination of alone time, reflection, social support, and staying busy and involved". However, while these strategies are challenging, more so during the lockdown, they are not impossible.

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And while nothing can replace physical proximity and touch for example, Dr Bedar says that with the use of technology, social contact and interaction are easily available in this day and age.

"Don't hesitate to reach out and ask for support, a (virtual) shoulder to cry on or even just a means to distract yourself for a bit through a chat or a laugh. Many people at this time are reconnecting with old friends and family and this can be immensely helpful in grief. Small online meet ups, one-on-one video calls are all doable and are valuable sources of social connectedness at this time."

In addition, many psychologists are also offering online sessions during this crisis which can be easily accessed. "Everyone seems to have suddenly discovered telehealth. But people need to be very careful who is at the other end of the line. Use services that are linked to reputable institutions and don't fall for anyone and everyone claiming to be counsellors," cautions Dr Hashmi.

The King Edward Medical University's TelePsychiatry helpline (042-99214724, 03126765604, Skype: kemu.psy@gmail.com) and its affiliated hospitals, including Mayo Hospital (Lahore's designated hospital for Covid-19 patients), have recently started a telemedicine department offering free, 24/7, expert advice for psychiatry and mental health, informs Dr Hashmi. In addition, Sehat Kahani is also offering free of cost services in mental health and various other specialities for the next three months.

*. Person not named to protect privacy*. Some case details have been changed to protect identities